Mercadotecnia social Thrasher JF y col.

Assessing the impact of cigarette package health

warning labels: a cross-country comparison
in Brazil, Uruguay and Mexico
James F Thrasher, PhD, MA, MS,(1,2) Victor Villalobos, MS,(1) André Szklo, PhD,(3) Geoffrey T Fong, PhD,(4, 5)
Cristina Pérez, BA,(3) Ernesto Sebrié, MD, MPH,(6) Natalie Sansone, BA,(4) Valeska Figueiredo, PhD,(3)
Marcelo Boado, PhD,(7,8) Edna Arillo-Santillán, MPH,(1) Eduardo Bianco, MD.(8)

Thrasher JF,Villalobos V, Szklo A, Fong GT, Pérez C, Sebrié E,
Sansone N, Figueiredo V, Boado M, Arillo-Santillán E, Bianco E.
Assessing the impact of cigarette package health warning labels:
a cross-country comparison in Brazil, Uruguay and Mexico.
Salud Publica Mex 2010;52 suppl 2:S206-S215.
Thrasher JF,Villalobos V, Szklo A, Fong GT, Pérez C, Sebrié E,
Sansone N, Figueiredo V, Boado M, Arillo-Santillán E, Bianco E.
Impacto de advertencias sanitarias del empaquetado de cigarros:
un análisis comparativo en Brasil, Uruguay y México.
Salud Publica Mex 2010;52 supl 2:S206-S215.

Abstract
Objective. To assess the impact of different health warning
labels (HWL). Material and Methods. Data from the Inter-
national Tobacco Control Survey (ITC Survey) were analyzed
from adult smokers in Brazil, Uruguay and Mexico, each of
which used a different HWL strategy (pictures of human suf-
fering and diseased organs; abstract pictorial representations
of risk; and text-only messages, respectively). Main outcomes
were HWL salience and cognitive impact. Results. HWLs in
Uruguay (which was the only country with a HWL on the
front of the package) had higher salience than either Brazilian
or Mexican packs. People at higher levels of educational attain-
ment in Mexico were more likely to read the text-only HWLs
whereas education was unassociated with salience in Brazil
or Uruguay. Brazilian HWLs had greater cognitive impacts
than HWLs in either Uruguay or Mexico. HWLs in Uruguay
generated lower cognitive impacts than the text-only HWLs
in Mexico. In Brazil, cognitive impacts were strongest among
smokers with low educational attainment. Conclusions.This
study suggests that HWLs have the most impact when they
are prominent (i.e., front and back of the package) and include
emotionally engaging imagery that illustrates negative bodily
impacts or human suffering due to smoking.
Resumen
Objetivo.  Evaluar el impacto de diferentes advertencias
sanitarias (AS). Material y métodos. Se analizaron datos
de la Encuesta Internacional para el Control del Tabaco (ITC
Survey), un estudio de fumadores adultos en Brasil, Uruguay
y México, tres países con distintas AS (con imágenes de sufri-
miento humano y órganos enfermos; con imágenes abstractas
del riesgo; mensajes de solo texto, respectivamente). Se ana-
lizó prominencia e impacto cognitivo de las AS. Resultados.
Las AS de Uruguay (que era el único país con AS en la parte
frontal del paquete) tuvieron una mayor prominencia que
en Brasil o México. En México, la gente que tenía un nivel
de educación mayor  eran mas propensos a leer mensajes
de advertencia, mientras que educación no se asoció con
prominencia en Brasil o Uruguay. Las AS de Brasil tuvieron un
mayor impacto cognitivo y conductual que las AS de Uruguay
o México. Las AS de Uruguay generaron un menor impacto
cognitivo y conductual que las AS de sólo texto en México.
En Brasil, los impactos cognitivos fueron los más fuertes entre
fumadores con un bajo nivel educacional. Conclusiones. Este
estudio sugiere que las AS tienen el mayor impacto cuando
son prominentes (por ej. en el frente y la parte trasera del
paquete) e incluyen imágenes emocionalmente llamativas
que muestran impactos negativos en el cuerpo o sufrimiento
humano debido al fumar.

Keywords: tobacco; health policy; product labeling; warning; Palabras clave: tabaco; política de salud; etiquetado de pro-
mass media ductos; aviso; medios de comunicación

(1) Instituto Nacional de Salud Pública. Cuernavaca, Morelos, México.

(2) Arnold School of Public Health, University of South Carolina, South Carolina, USA.
(3) Instituto Nacional de Cancer. Rio de Janeiro, Brasil.
(4) Department of Psychology, University of Waterloo. Waterloo, Ontario, Canada.
(5) Ontario Institute for Cancer Research. Toronto, Ontario, Canada.
(6) Department of Health Behavior, Roswell Park Cancer Institute. Buffalo, New York, USA.
(7) Departamento de Sociología, Universidad de la República. Montevideo, Uruguay.
(8) Centro de Investigación para la Epidemia de Tabaquismo. Montevideo, Uruguay.

Received on: February 5, 2010 • Accepted on: June 2, 2010

Address reprint requests to: James F. Thrasher, PhD. Department of Health Promotion, Education, and Behavior.
Arnold School of Public Health, University of South Carolina. 800 Sumter Street, Room 215, Columbia, SC 29208, USA.
E-mail: thrasher@mailbox.sc.edu

S206 salud pública de méxico / vol. 52, suplemento 2 de 2010

Impact of health warning labels Mercadotecnia social

T he World Health Organization’s Framework

Convention on Tobacco Control (WHO-FCTC)
promotes the use of strong, effective health warning
labels (HWLs) on tobacco product packaging in order
to inform smokers and potential smokers of the health
risks of smoking.1 In particular, the WHO-FCTC stipu-
lates that HWLs on cigarette packaging “should be 50%
or more of the principal display areas but shall be no
less than 30%” and “may be in the form of or use pic-
tures or pictograms.”2 Recent research supports these
standards, with consistent evidence that warning labels
that combine pictures and text are more effective than
text-only messages in engaging smokers, increasing
their knowledge about risks, promoting quitting, and
decreasing demand for cigarettes.3-11 However, further
research is needed to assess which pictorial HWL for-
mats and content work best, as well as to assess the
potential modification of these effects by subgroup
characteristics that contribute to tobacco-related health
disparities.
Little is known about whether some types of picto-
rial images on cigarette packs are more likely than other
types to influence smokers’ knowledge, attitudes, and
behaviors. However, focus groups in Canada,12 as well as
experimental research in the US,13 Mexico14 and Brazil15,16
suggest that gruesome imagery has greater impact than
abstract imagery. This finding is supported by surveys
of adult smokers in Uruguay, Thailand, and Australia,
which suggest that after each country instituted pictorial
HWLs for the first time, the warnings had a lower impact
in Uruguay than in the other countries.* This difference
can be attributed to the relatively abstract imagery of
HWLs in Uruguay (Figure 1), which contrasts with the
more gruesome illustrations of smoking consequences
in the other countries.
* Thrasher JF, Villalobos V, Cummings KM, Borland R, Yong H-H.
Smokers’ reactions to health warnings labels with pictorial imagery in
Uruguay, Thailand and Australia: Does fear arousing content matter?
Under review.

Figure 1
Cigarette package health warning label (HWL) characteristics in Brazil, Uruguay & Mexico, 2008-2009

Brazil (2009) Uruguay (2008) México (2008)

HWL size as Front None 50% None

% of principal
display areas Back 100% 50% 50%
HWL
format Pictures Yes Yes No
Years of exposure to
7 (2002-2009) 2 (2006-2008) 4 (2004-2008)
format at data collection
Pictorial image type Diseased organs (4) & human suffe-
Abstract imagery (4), each with
(number of message ring imagery (4), abstract imagery (2), Text only (3)
different text
variants) each with different text

HWL Example HWLs

content

Quit line mentioned Yes Yes No

Years of exposure to
HWL content at data 5 (2004-2009) 1 (2007-2008) 4 (2004-2008)
collection

salud pública de méxico / vol. 52, suplemento 2 de 2010 S207

 Mercadotecnia social
Research has generally not examined whether
HWLs formats have different effects across sociodemo-
graphic groups within different countries. As tobacco
policies and programs have been implemented in high-
income countries, smoking has become concentrated
within socially disadvantaged groups.17 This disparate
concentration may also occur in low- and middle-
income countries unless policies and programs have
even impacts or help offset disparities that arise from
certain interventions, including communication inter-
ventions to which low SES populations have lower
levels of exposure or are less responsive. Warning labels
potentially communicate health risks to smokers across
all SES groups, and picture warning labels may reach
an even greater audience as they overcome issues with
literacy.8,18 As such, health warning labels could help
prevent and/or remediate smoking-related tobacco
disparities. In this regard, studies of the differential
impact of mass media campaigns are suggestive. Some
mass media campaigns impact high- but not low-SES
groups;19 however, other research has found that emo-
tionally evocative ads and testimonials appear to work
better among lower than higher SES groups.20 A key
research question for the future development of HWL
messaging policies is whether pictorial HWLs are better
than text-only HWLs in influencing low SES groups, and
whether testimonial and emotionally evocative pictorial
HWLs may do this more effectively than other types
of pictorials. We address this question in this article
by analyzing data from International Tobacco Control
Policy Evaluation Project (ITC Project) surveys in three
Latin American countries with HWLs that likely vary
in emotional intensity that they provoke.
Health warning labels and the tobacco
control context in Brazil, Uruguay and
Mexico
At the time of ITC survey data collection in 2008-
2009, the health warning labels in Brazil, Uruguay
and Mexico were quite different (Figure 1). In Brazil,
HWLs covered 100% of the back of each cigarette pack,
whereas they covered 50% of the back in Uruguay and
Mexico. Unlike Brazil and Mexico, Uruguay’s HWL
also covers the front of the pack. Brazil has had picto-
rial warning labels since 2002,21 which were revised in
2004 and again in 2009,16 after the current study data
were collected.16 The 2004 HWLs included four images
of human suffering, four images of gruesome diseased
organs and death, and two abstract representations
of poison (dead rat) and impotence (limp cigarette).
Uruguay implemented its first round of eight pictorial
HWLs in 2006, with a second round in 2008, and sub-
S208
Thrasher JF y col.
sequent rounds after data were collected. The first two
rounds of pictorial HWLs consisted of abstract repre-
sentations of smoking-related consequences, which in
the second round took the form of a vial with skull and
crossbones, dynamite, and a tombstone. The text-only
HWLs in Mexico have been in existence since 2004,
and include three messages (Smoking causes cancer
and emphysema; Quitting smoking reduces important
health risks; Smoking during pregnancy increases risk
of premature birth and low birthweight babies).
This paper uses cross-sectional data from these
three countries with distinct HWL policies in order to
explore the following hypotheses: 1) In Mexico, which
has text-only HWLs, greater HWL salience and cogni-
tive impact will be associated with higher educational
attainment, whereas these associations will be negative
in Brazil and Uruguay, which have pictorial HWLs; 2) In
Uruguay, which is the only country with a HWL on the
front of the package, HWL salience will be greater than
in other countries; In Brazil HWLs will be more salient
than in Mexico, due to having more space dedicated to
the HWL; 3) The cognitive and behavioral impact of
HWLs will be greater in Brazil than in Uruguay, which
will be greater than in Mexico.
Material and Methods
Study sample: As part of the International Tobacco Con-
trol Policy Evaluation Project (ITC-Project), data were
collected from adult smokers in Brazil (Wave 1, April to
June 2009), Uruguay (Wave 2, September to December
2008), and Mexico (Wave 3, November to December
2008). At the time of analysis, there was only one survey
wave for Brazil, which occurred when its HWLs had
included pictorials for seven years; hence, we selected
the most recent ITC survey administrations in Uruguay
and Mexico, so that the length of time that participants
would have been exposed to the HWLs was as compa-
rable as possible (since 2006 and 2004, respectively). In
Brazil, telephone-administered surveys were conducted
with adult smokers using an area stratified random
sampling strategy, yielding a representative sample of
1 215 smokers who lived in three of the four largest cities
in Brazil (Rio de Janeiro, Porto Alegre, and Sao Paulo).
For Brazil, the household telephone contact rate was
31.7% and the cooperation rate among smokers identi-
fied as eligible was 85.2%. Eligible smokers were those
who smoked at least monthly and at least 100 lifetime
cigarettes. The Uruguayan and Mexican administrations
of the ITC surveys were conducted using a similar strati-
fied, multi-stage sampling strategy that involved face-to-
face interviews with randomly selected adult smokers,
defined as those who had smoked at least once during
salud pública de méxico / vol. 52, suplemento 2 de 2010
Impact of health warning labels
the previous week and at least 100 lifetime cigarettes (for
details, see Thrasher et al., 2009). The wave 1 Uruguayan
sample consisted of households in the capital city of
Montevideo, where 40% of the countries 3.5 million
people live. In Montevideo, 95% of households selected
were contacted and 76% of selected smokers agreed to
participate. At wave 2 (n=1378), which comprises the
analytic sample for the present study, 66% (585/885) of
participants were successfully re-interviewed, with re-
plenishment of smokers in Montevideo (n=391) and new
samples (n=402) selected using the same procedures
in four additional smaller cities (Salto, Maldonado,
Durazno, and Rivera), whose population ranged from
30 000 to 100 000. The household enumeration and
participation rates in these new cities were 88% and
78%, respectively. People who no longer smoked (n= 85)
were excluded from the analytic sample. In Mexico, the
wave 1 (2006) sampling frame consisted of households
within each of four of the six largest cities in Mexico
(Mexico City, Guadalajara, Tijuana, and Ciudad Juárez),
but which was expanded at wave 3 (2008) to include
three additional cities that are amongst the twelve most
populous in Mexico (Monterrey, Puebla, and Mérida).
The household enumeration rate at wave 1 was 64% and
the cooperation rate among selected participants was
89%. At wave 2 in 2007, 70% (756/1079) were success-
fully followed up, with replenishment of this sample
with 289 randomly selected smokers who lived within
the same census tracts where the loss to follow up oc-
curred. The wave 3 sample (n=2010), which comprises
the analytic sample for the present study, includes 73%
(762/1045) of those followed from wave 2, a replenish-
ment sample of 300 smokers randomly selected from the
same census tracts, as well as new samples in three cities
(n=813) and in Mexico City (n=135). Household contact
and cooperation rates for this new sample were 79% and
70%, respectively. People who were no longer smokers
(n= 149) were excluded from the analytic sample. For
each country, sampling weights were developed to
account for the likelihood of participant selection. To
produce more efficient estimates of association,22 the
weights used for model estimation were rescaled to
sum to the sample size within each country. Protocols
were approved by ethics review boards in each country
(INCA, Brazil; Universidad de la República, Uruguay;
INSP, México). Before participating, Brazilian smokers
provided oral informed consent, while Uruguayan and
Mexican smokers provided written informed consent.
Measurement
Exposure and reactions to health warning labels: Warning
label salience was assessed with two questions: how
salud pública de méxico / vol. 52, suplemento 2 de 2010
Mercadotecnia social
often smokers noticed HWLs; and how often they read
or looked closely at them. Responses for each were di-
chotomized (1=often or very often vs. 0=never or once in
a while in Uruguay and Mexico or vs. 0=never, rarely or
sometimes in Brazil). Cognitive impact was assessed with
three questions: how much HWLs made participants
think about the health risks of smoking; how much
HWLs made participants think about quitting; and how
often HWLs made them think about quitting. For simple
comparative analises, response options were dichoto-
mized (i.e., 0=none vs. 1=a little, somewhat, or a lot for the
first two questions; 0=none or a little vs. 1=a lot for the
third). These three questions were also rescaled to have
the same range of responses and averaged together to
create a scale, which had good internal consistency in
all three countries (alpha=0.77, 0.78, and 0.71 in Brazil,
Uruguay and Mexico, respectively). Finally, assessment
of behavioral impact of HWL involved asking if, in the
last month, health warnings had stopped participants
from having a cigarette when they were about to smoke
one (i.e., 0=never, 1=at least once).
Smoking-related variables: Smokers were asked if they
smoke everyday or less frequently (coded as 1 and 0,
respectively). Participants were also asked how much
smoking had harmed their health, as well as how
much they worried that smoking would harm them
in the future. Response options for each of these two
questions (not at all, somewhat, a lot) were dummy
coded, with “not at all” as the reference group. Finally,
participants were asked if they had heard of or ever
used a toll free quit line.
Sociodemographics: Sociodemographic characteristics
were assessed with standard questions on sex, age, and
educational attainment. Although educational systems
vary in each country, a four-level variable was a created
that was a meaningful within and across groups. For
Brazil, the reported number of years of education were
collected and recoded to reflect comparable levels of
attainment: primary school or less, 0-4 years; secondary
school, 5-8 years; high school, 9-11 years; and university
or higher, 12 or more years. For Uruguay and Mexico,
categorical variables were recoded to reflect primary
school or less, secondary school, high school or technical
school, and university or higher. In pooled analyses, dif-
ferences between countries were assessed with dummy
variables that treated Mexico as the referent group.
Interactions were tested by multiplying the country
dummy variable with the variable of interest.
Analysis
All analyses were conducted using STATA, version 9.
Sociodemographics and smoking-related character-
S209
 Mercadotecnia social Thrasher JF y col.

istics were assessed without adjusting for the survey
design. T-tests and chi-square tests were used to assess
differences in these characteristics across countries,
without survey adjustment. All other univariate (i.e.,
health warning label indicators and quit line vari-
ables), bivariate, and multivariate analyses involved
adjustment for survey design and sampling weights.
In models stratified by country, multivariate logistic
models were estimated for dichotomous HWL indica-
tors (i.e., salience variables and behavioral impact), and
linear regression models for the continuous, cognitive
impact HWL scale. In these models, HWL indicators
were regressed on sociodemographics, daily smoking,
and risk perceptions. In pooled analyses, the same
dependent and independent variables were assessed,
while also including dummy variables for country and,
where appropriate, a variable to express the interaction
between country and the variable of interest. For all
analyses, p-values <0.05 were used to indicate statisti-
cal significance.
Results
Table I shows the characteristics of the analytic samples
for this study. The Brazilian sample was slightly older
(mean age 44.4) and had higher educational attainment
than the Uruguayan and Mexican samples (mean age
40.8 and 40.2, respectively). Participants in Brazil also
held stronger beliefs about the harm they had already
experienced from tobacco use, with similar levels
of perceived harm among Uruguayan and Mexican
participants. Brazilian and Mexican participants had
comparable expectations about future harms they would
experience from smoking, with Uruguayan participants

Table I
Sample characteristics and responses to health warning labels in Brazil, Uruguay and Mexico

Brazil Uruguay Mexico

Characteristics
(n=1 215) (n=1 294) (n=1 867)

Agec,f (mean)   44.4 40.8 40.2

Malec,d,I (%)   57.3 49.1 61.4
Primary or less 10.2 25.0 29.3
Secondary 23.2 44.4 28.7
Educationc,f,I (%)
High or technical school 38.5 16.5 30.2
University or more 28.1 14.2 11.8
Daily smokerf,i (%) Daily 92.8 91.1 67.2
Not at all 18.2 31.9 31.0
Smoking has harmed healthc,f
Some 40.6 45.4 43.2
(%)
A lot 41.1 22.7 25.7
Not at all 9.0 15.3 7.7
Smoking will harm health c,i
Some 33.2 37.8 34.7
(%)
A lot 57.8 46.9 57.6
% heard of toll-free quit linec,f,i 93.3 38.7 28.6
Quit line* (%)
% ever called toll-free quit linec,f 7.1 1.1 1.6
Noticed HWLs often or very oftenc,i 45.5 62.3 42.9
Read or looked closely at HWLs often or very oftenc,i 29.5 42.4 31.9
HWLs made you think about harms of smokingc,f,i 83.7 62.9 72.3
HWLs made you think about quittingc,f,i 72.6 47.1 57.7
Responses to health warning Thought a lot about quitting because of HWLsc,f,i 39.3 5.7 12.4
labels (HWLs)* (%) Stopped smoking when about to light a cigarette because
38.2 17.0 26.3
of HWLsc,f,i
Want less HWL information 2.7 6.8 4.3
Want equal HWL information 40.4 61.5 48.6
Want more HWL informationc,f,i 56.8 31.6 47.12

* Survey-adjusted estimates shown and compared for quitline and HWL-related questions, but not for other questions
a b c
BR vs. UY different at p<0.01; BR vs. UY different at p<0.05; BR vs. UY different at p<0.001
d
BR vs. MX different at p<0.01; e BR vs. MX different at p<0.05; f
BR vs. MX different at p<0.001
g
UY vs. MX different at p<0.01; h UY vs. MX different at p<0.05; i
UY vs. MX different at p<0.001

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Impact of health warning labels Mercadotecnia social

indicating lower expectations about future harms.
Brazilian participants were much more likely than
Uruguayan or Mexican participants to have heard of the
quit line (i.e., 93% vs 39% and 29%, respectively) and to
have called the quit line (7% vs 1% and 2%, respectively).
When assessing warning label responses, indicators of
warning label salience (noticing and reading HWLs of-
ten or very often) were significantly higher in Uruguay
(62.3% and 42.4%, respectively) than in either Brazil
(45.5% and 29.5%, respectively) or Mexico (42.9% vs.
31.9%, respectively). However, indicators of cognitive
processing and behavioral impact of HWLs were all
higher in Brazil (38% to 84%) than in either Uruguay
(6% to 63%) or Mexico (12% to 72%), with Uruguayans
indicating lower levels of cognitive impact than Mexi-
cans. Most Brazilian participants also indicated that they
wanted more information on HWLs (57%), which was
higher than their Uruguayan and Mexican counterparts
(32% and 47%, respectively).
Noticing and reading/looking at HWLs
Logistic regression models were estimated to assess fac-
tors associated with the noticing and reading/looking
at HWLs within and across countries (Table II). In the
case of Mexico, educational attainment had a positive,
independent association with salience in both models
(B=0.14, p<0.05; B=0.18, p<0.01), whereas education
had no statistically significant association with either
outcome in Brazil or Uruguay. In the models stratified by
country, other sociodemographic and smoking-related
variables generally indicated no statistically significant
association with HWL salience indicators, or they were
associated with one, but not the other outcome. Data
were then pooled across countries to assess country-
level effects and interactions. In the model estimating
predictors of noticing HWLs, higher educational attain-
ment was positively associated (B=0.08, p<0.05), and
those who perceived a lot of future harm from smoking

Table II
Multivariate logistic models regressing health warning label salience indicators on sociodemographics
and smoking-related variables, by country and pooled

Noticed HWLs often or very often Read or looked closely at HWLs often or very often
Brazil Uruguay Mexico Pooled1 Pooled2 Brazil Uruguay Mexico Pooled1 Pooled2
OR (95%CI) OR (95%CI) OR (95%CI) OR (95%CI) OR (95%CI) OR (95%CI) OR (95%CI) OR (95%CI) OR (95%CI) OR (95%CI)

0.00 -0.01 0.00 0.00 -0.00 -0.01 -0.01 0.01 0.00 -0.00
Age*
(0.00) (0.01)a (0.00) (0.00) (0.00) (0.01)b (0.01) (0.00) (0.00) (0.00)
0.09 -0.03 0.14 0.08 -0.12 0.06 -0.13 0.18 0.05 0.15
Education*
(0.07) (0.08) (0.06)a (0.04)a (0.06) a (0.08) (0.08) (0.06)b (0.04) (0.06)a
1.09 1.03 1.08 1.06 1.06 1.09 1.14 1.01 1.06 1.07
Sex
(0.84,1.41) (0.74,1.43) (0.85,1.38) (0.90,1.24) (0.91,1.24) (0.81,1.45) (0.83,1.58) (0.79,1.31) (0.90,1.26) (0.90,1.26)
Daily-non daily 0.83 1.1 0.92 0.94 0.94 1.04 0.79 1.06 1.04 1.03
smoker (0.50,1.37) (0.60,2.0) (0.71,1.19) (0.76,1.18) (0.75,1.17) (0.59,1.83) (0.47,1.33) (0.81,1.38) (0.83,1.30) (0.83,1.29)
Smoking has harmed 0.86 0.96 0.92 0.93 0.93 1.24 0.75 0.82 0.88 0.88
some vs. none (0.59,1.26) (0.65,1.41) (0.69,1.23) (0.76,1.13) (0.76,1.13) (0.79,1.95) (0.51,1.10) (0.61,1.11) (0.72,1.09) (0.72,1.09)
Smoking has harmed 1.01 1.16 1.41 1.22 1.22 0.95 0.83 1.24 0.99 0.99
a lot vs. none (0.67,1.51) (0.72,1.84) (1.01,1.98)a (0.97,1.53) (0.98,1.53) (0.58,1.53) (0.54,1.30) (0.86,1.77) (0.78,1.25) (0.78,1.25)
Smoking will harm 1.36 0.9 1.08 1.06 1.06 0.91 1.25 0.97 1.06 1.07
some vs. none (0.80,2.31) (0.54,1.49) (0.67,1.73) (0.79,1.41) (0.80,1.41) (0.49,1.72) (0.77,2.05) (0.59,1.58) (0.78,1.44) (0.79,1.45)
Smoking will harm a 2.04 1.48 1.72 1.66 1.67 1.72 1.95 1.58 1.74 1.75
lot vs. none (1.21,3.46)b (0.88,2.49) (1.08,2.75)a (1.25,2.21)c (1.26,2.22)c (0.92,3.22) (1.18,3.23)b (0.98,2.55) (1.28,2.35)c (1.29,2.37)c
2.38 2.9 1.57 2.22
Uruguay vs Mexico  
(1.92,2.94)c (2.06,4.09)c (1.27,1.94)c (1.57,3.14)c
0.91 0.9 0.76 0.78
Brazil vs Mexico  
(0.75,1.11) (0.63,1.27) (0.62,0.94)b (0.54,1.14)
Uruguay* 0.85 0.76
 
Education (0.70,1.04) (0.62,0.93)b
1.00 0.96
Brazil* Education                
(0.83,1.19) (0.79,1.16)
N 1 190 1 160 1 702 4 052 4 052 1 192 1 162 1 703 4 058 4 058

* Estimates shown for age and education are beta coefficients, not odds ratios, and thus, the value of an age or education coefficient under
the null hypothesis is 0, not 1
a
p<0.01; b p<0.05; c p<0.001

salud pública de méxico / vol. 52, suplemento 2 de 2010 S211

 Mercadotecnia social Thrasher JF y col.

were more likely to notice HWLs than those who did
not perceive these harms (AOR=1.66). Furthermore,
Uruguayans were more likely than Mexicans to notice
HWLs (AOR=2.38), with no difference between Mexi-
cans and Brazilians. Tests of interaction between edu-
cation and country were not significant. In the pooled
model to assess predictors of reading HWLs, reading
was also significantly higher among Uruguayans than
among Mexicans, but a statistical interaction was found
between Uruguay and education such that the positive
association between education and reading HWLs in
Mexico was significantly stronger than the lack of as-
sociation found in Uruguay.
Cognitive impact of HWLs
p<0.001), but unassociated in Uruguay and Mexico.
Non-daily smokers and those with greatest perceived
current and future harms due to smoking were also
generally more likely to report cognitive impacts due
to HWLs. These relationships maintained statistical
significance in the pooled, multivariate model, where
Uruguayans were significantly less likely than Mexicans
to experience cognitive HWL impacts (B=-0.09, p<0.05),
whereas Brazilian counterparts were more likely to
experience these impacts (B=0.80, p<0.001). A second
pooled model indicated a statistically significant interac-
tion between Brazil and education, such that the inverse
association found between education and cognitive
impacts from HWLs was significantly stronger than the
lack of association found in Mexico.

Linear regression models were also estimated, regress-
ing the scale of cognitive HWL impact on sociodemo-
graphics and smoking-related variables (Table III). In the
models stratified by country, education was inversely
associated with cognitive impacts in Brazil (B= -0.20,
Behavioral impact of HWLs
Finally, logistic regression models were estimated to
determine the factors associated with reporting that
in the last month, HWLs stopped a participant from

Table III
Multivariate regression models of cognitive and behavioral impacts of health warning labels
on sociodemographics and smoking-related variables, by country and pooled

Multivariate linear regression model of cognitive impact of HWLs Multivariate logistic regression model of not smoking because of HWLs
Brazil Uruguay Mexico Pooled1 Pooled2 Brazil Uruguay Mexico Pooled1 Pooled2
B (SE) B (SE) B (SE) B (SE) B (SE) OR (95%CI) OR (95%CI) OR (95%CI) OR (95%CI) OR (95%CI)

0.00 0.00 0.00 0.00 0.00 -0.01* 0.00* 0.01* 0.00* 0.00*
Age
(0.00) (0.00) (0.00) (0.00) (0.00) (0.01) (0.01) (0.00)a (0.00) (0.00)
-0.20 -0.05 -0.01 -0.08 -0.02 -0.29* -0.22 a* -0.05* -0.17* -0.08*
Education
(0.03)c (0.03) (0.02) (0.01)c (0.02) (0.08)c (0.10)a (0.07) (0.05)c (0.07)
-0.03 0.06 -0.02 -0.01 -0.01 0.84 1.22 0.92 0.98 0.97
Sex
(0.06) (0.06) (0.04) (0.03) (0.03) (0.64,1.11) (0.82,1.83) (0.70,1.21) (0.82,1.17) (0.82,1.16)
Daily vs. non-daily -0.18 -0.32 -0.22 -0.22 -0.23 0.69 0.45 0.74 0.7 0.7
smoker (0.11) (0.11)b (0.05)c (0.04)c (0.04)c (0.40,1.16) (0.25,0.80)b (0.56,0.99)a (0.55,0.89)b (0.55,0.89)b
Smoking has harmed 0.18 0.01 0.09 0.08 0.1 1.36 0.97 1.37 1.28 1.29
some vs. none (0.09)a (0.07) (0.05) (0.04)a (0.04)b (0.86,2.15) (0.59,1.60) (0.98,1.93) (1.01,1.63)a (1.02,1.64)a
Smoking has harmed 0.30 0.30 0.26 0.29 0.29 1.69 1.06 1.39 1.43 1.43
a lot vs. none (0.10)b (0.08)c (0.07)c (0.04)c (0.04)c (1.06,2.70)a (0.60,1.86) (0.94,2.07) (1.11,1.86)b (1.11,1.86)b
Smoking will harm 0.47 0.39 0.10 0.31 0.31 1.50 2.38 1.41 1.68 1.69
some vs. none (0.13)c (0.06)c (0.08) (0.05)c (0.05)c (0.76,2.97) (1.09,5.20)a (0.81,2.47) (1.15,2.45)b (1.16,2.46)b
Smoking will harm a 1.15 0.75 0.35 0.73 0.71 3.56 5.12 1.43 2.65 2.63
lot vs. none (0.13)c (0.07)c (0.08)c (0.05)c (0.05)c (1.82,6.97)c (2.43,10.79)c (0.83,2.49) (1.83,3.83)c (1.82,3.81)c
-0.09 -0.03 0.65 0.74
Uruguay vs Mexico
(0.04)a (0.06) (0.50,0.83)c (0.51,1.09)
0.80 1.13 2.01 2.79
Brazil vs Mexico
(0.04)c (0.07)c (1.62,2.49)c (1.94,3.99)c
-0.04 0.89
Uruguay* Education
(0.03) (0.70,1.13)
-0.20 0.81
Brazil* Education
(0.04)c (0.67,0.98)a
N 1 183 1 146 1 692 4 008 4 008 1 193 1 158 1 705 4 056 4 056

* Estimates shown for age and education are beta coefficients, not odds ratios, and thus, the value of an age or education coefficient under
the null hypothesis is 0, not 1
a
p<0.01; b p<0.05; c p<0.001

S212 salud pública de méxico / vol. 52, suplemento 2 de 2010

Impact of health warning labels
smoking a cigarette when he was about to light one
(Table III). Results were generally consistent with those
found for the models estimating factors associated with
the cognitive impact of HWLs, including the inverse
association with education in Brazil (B=-0.29, p<0.001)
although this was also found for Uruguay (B=-0.20,
p<0.05). In pooled models, Uruguayans were less likely,
and Brazilians more likely than Mexicans to report this
outcome (AORUY vs MX=0.65, p<0.001; AORBR vs MX=2.01,
p<0.001). In the model that tested interactions between
country and educational attainment, results indicated
that the inverse association between education and
behavior in Brazil was significantly different from the
lack of association found in Mexico.
Discussion
The results from this study confirmed key study hypoth-
eses. The salience of HWLs, as indicated by noticing and
reading or looking closely at the package, was signifi-
cantly higher in Uruguay than in either Brazil or Mexico.
The length of time since introduction of the newest
round of HWLs in each country may help explain the
greater salience in Uruguay, as attention to HWLs
“wears out” over time,7 and they were introduced only
2 years prior to data collection in Uruguay, compared to
4 and 5 years prior in Mexico and Brazil, respectively.
However, the greater salience of Uruguayan HWLs is
also likely due to its being the only country with HWLs
on both the front and back of the pack. The history of
tobacco packaging confirms this contention, as a key
innovation in cigarette marketing involved the display
of brand imagery on both sides of the pack in order to
communicate this imagery as frequently as possible.23,24
Hence, countries should follow WHO-FCTC guidelines
for implementing prominent HWLs on all primary
surfaces of the pack.25
The salience of text-only Mexican and pictorial
Brazilian HWLs was comparable, suggesting that the
salience of pictorial HWLs can be reduced to that found
for text only HWLs when covering only one side. Other
studies have also found equivalent salience of pictorial
(Canada and Australia) and text only (United Kingdon)
HWLs when they are similarly prominent on both the
front and back of the pack.7,9 However, the argument
in favor of pictoral HWLs is bolserted by our finding
that educational attainment was positively associated
with salience in Mexico, but unassociated either Brazil
or Uruguay. Text-only HWLs, like those in Mexico, may
be more likely to be noticed and read by people at higher
levels of educational attainment; thus, text-only HWLs
may be less effective with more socioeconomically dis-
advantaged smokers. Indeed, the potential to overcome
salud pública de méxico / vol. 52, suplemento 2 de 2010
Mercadotecnia social
health literacy issues is one of the key advantages of
pictorial warnings over text-only warnings.
Our results also suggest that the Brazilian strategy
of using depictions of human suffering and gruesome
bodily impacts of smoking on its HWLs had a greater
cognitive and behavioral impact than either the abstract
imagery used in Uruguay or the text-only HWL format
used in Mexico. This is consistent with experimental
research,14 although it has not been studied before in sur-
veys because countries’ pictorial HWL systems have not
been distinct enough to allow for such a comparison.9
The abstract imagery used in Uruguay appears to have
generated even lower cognitive and behavioral impacts
than the text-only Mexican HWLs. Another key finding
concerns the inverse association between educational at-
tainment and cognitive and behavioral impacts of HWLs
in Brazil and Uruguay, but not in Mexico. In pooled
analyses, statistically significant interactions involving
education and country suggest that this inverse associa-
tion is significantly different in Brazil when compared
to Mexico - in other words, testimonial and gruesome
imagery appears to do a better job of communicating
risks and promoting thoughts about quitting to smok-
ers with lower educational attainment than those with
higher attainment. This is consistent with other studies
of mass media campaigns to promote cessation.20 Hence,
HWL images that depict the gruesome nature of tobacco-
related disease and those that depict the concrete human
suffering from smoking-related consequences may help
offset smoking-related disparities across SES groups
or, in the case of countries that are only beginning to
experience the tobacco epidemic, prevent them from
even happening.
In general, Brazilian smokers had higher perceived
current and future harms due to smoking, perhaps re-
flecting the country’s longer tobacco control program
when compared to Mexico and Uruguay. Our results
also indicate that the Brazilians were more likely than
Uruguayans or Mexicans to be aware of (93% vs 39%
and 29%, respectively) and to have used (7% vs 1% and
2%, respectively) telephone-based cessation assistance,
which is advertised in all Brazilian tobacco control me-
dia campaigns and HWLs, but only in media campaigns
in Mexico and Uruguiay. Across all three countries,
however, those who perceived greater future conse-
quences from smoking were also more likely to respond
to HWLs, whether examined in terms of HWL salience,
cognitive impact, or behavioral impact. These cross-
sectional data do not allow determination of whether
HWLs generate these concerns about future harm or
whether this predisposition contributes to selective at-
tention to HWLs. Longitudinal analyses are needed to
determine how HWLs contribute to and interact with
S213
 Mercadotecnia social
these perceptions to promote downstream quit attempts.
Indeed, a clear determination of the public health impact
of different HWL strategies will come from examining
their impact on consumption, including quitting.
Although the study results are suggestive of the
greater impact of front-of-pack HWLs and the use of
emotionally evocative imagery, our interpretations
should be tempered by a few additional observations.
First of all, HWL characteristics varied in size and po-
sitioning, as well as in content. Conclusions about the
greater cognitive and behavioral impact of Brazilian
than Uruguayan HWLs may be partly explained by
Brazilian HWLs covering 100% of the back of the pack,
instead of 50% of each side. However, our conclusions
regarding the greater effectiveness of the Brazilian-
style pictorial HWLs are supported by our finding that
Uruguayan content had lower cognitive and behav-
ioral impacts than even the Mexican text-only HWLs
that covered less surface area (50% of the back) than
Uruguayan labels. Furthermore, this difference was
detected in spite of the overall greater salience of Uru-
guayan labels. Nevertheless, further research should be
conducted to determine whether the imagery of human
suffering has a greater impact than gruesome diseased
organs, or whether there are synergies between the two
that would not be obtained if either one or the other
strategy was adopted by itself.
The internal validity of the study may have been
compromised by a number of issues, including slightly
different response options offered for some variables.
Our use of educational attainment as an indicator of
SES is incomplete and may not adequately represent
this concept. Nevertheless, educational attainment is
a reasonable indicator of literacy and the impact of
pictorials among populations with low literacy has not
been examined previously. In the case of Uruguay and
Mexico, whose first wave was fielded around the same
time, researchers worked to develop consistent and
harmonized translations to reduce measurement biases
introduced by survey translation; however, Brazil did
not undergo this process as it entered the study at a
later date, potentially biasing results in un predictable
ways. Differing data collection modes (i.e., telephone-
administered in Brazil and face-to-face in Uruguay and
Mexico) may have also biased results. Although the
coverage of phone lists in Brazil is quite high (São Paulo
77%, Rio de Janeiro 75,2% and Porto Alegre 86,6%.),26
smokers without landlines are likely to be from lower
SES groups and may respond differently to HWLs than
the smokers with lower educational attainment in our
sample. Finally, the Brazilian sample included monthly
smokers, whereas the Uruguayan and Mexican samples
excluded those who smoked less than weekly. However,
S214
Thrasher JF y col.
very few Brazilians smoked monthly, but not weekly,
and these few ar unlikely to influence results.
Further research should also account for how smok-
ers’ responses to HWLs interact with other features of
the tobacco control environment. Cross-country differ-
ences in tobacco control environments and histories
of education about tobacco could help account for our
findings; however, we focused our attention on theory-
based mediators of HWL impacts on behavior in order
to help rule out this possibility.27 Finally, despite the
population-based nature of our samples, non-response
may have biased the generalizability of our results to
the broader population within each country.
Overall, this study confirms WHO Article 11
implementation guidelines that countries should have
HWLs that prominently occupy both principal display
areas of cigarette packages and include pictorial im-
agery.25 Article 11 guidelines suggest that “culturally
appropriate pictures” be used, without further specifi-
cation. Our results suggest that pictures should include
emotionally engaging imagery that illustrates negative
consequences, using images of diseased organs or of
human suffering. HWLs in each of the three countries
have changed or are about to change in ways that will
further inform the further evolution of Article 11. In
2009, Brazil implemented a set of HWL images found
to promote extreme negative emotions and aversion.16
Since 2009, Uruguay includes more gruesome imagery,
and the pack space dedicated to HWLs has increased
to 80% on the front and back. In September 2010,
Mexico will implement pictorial HWLs that primarily
emphasize the health and emotional consequences of
smoking on important others. Furthermore, the picto-
rials will appear on the upper 30% of the front of the
pack, with 100% of the back dedicated to only text. Like
Uruguay, Mexico can renew HWL content on an annual
basis. The impact of the periodicity of HWL rotation
is not well understood. Longitudinal data from the
ITC survey will help understand the impacts of these
changes so that other countries can learn from these
experiences.
Declaration of conflicts of interest
We declare that we have no conflicts of interest.
Acknowledgements
Funding for data collection and analyses on this study
came from Consejo Nacional de Ciencia y Tecnología
(CONACyT Convocatoria Salud-2007-C01-70032),
with additional funding for analysis provided by the
National Cancer Institute (P01 CA138389) and an un-
salud pública de méxico / vol. 52, suplemento 2 de 2010
Impact of health warning labels Mercadotecnia social

restricted grant from Johnson & Johnson. Dr Ernesto 13. Nimbarte A, Aghasadeh F, Harvey C. Comparison of current US
and Canadian cigarette pack warnings. Int Q Community Health Educ
Sebrié was supported by the Flight Attendant Medical
2006;24(1):3-27.
Research Institute (FAMRI). 14. Thrasher JF, Allen B, Anaya-Ocampo R, Reynales LM, Lazcano-Ponce
EC, Hernández-Avila M. Análisis del impacto en fumadores Mexicanos
de los avisos gráficos en las cajetillas de cigarros [Analysis of the impact
References of cigarette package warning labels with graphic images among Mexican
smokers]. Salud Publica Mex 2006;48:S65-S75.
15. Nascimento B, Oliveira L,Vieira A, Joffily M, Gleiser S, Pereira M, et al.
1. WHO. WHO report on the global tobacco epidemic, 2008: The
Avoidance of smoking: The impact of warning labels in Brazil. Tob Control
MPOWER package. Geneva: World Health Organization, 2008.
2008;17:405-409.
2. WHO. Framework Convention on Tobacco Control. Geneva,
16. INCA. Brazil: Health warnings on tobacco products - 2009. Rio di
Switzerland: World Health Organization, Tobacco Free Initiative, 2003.
Janeiro: Ministereo de Saude, Instituto Nacional de Cancer, 2009.
3. Strahan E, White KS, Fong GT, Fabrigar L, Zanna M, Cameron R.
17. Link B. Epidemiological sociology and the social shaping of population
Enhancing the effectiveness of message labels on tobacco packaging: A
health. J Health Soc Behav 2008;49:367-384.
social psychological perspective. Tob Control 2002;11:183-190.
18. Thrasher JF, Rousu MC, Anaya-Ocampo R, Reynales-Shigematsu LM,
4. Hammond D, Fong GT, MacDonald P, Cameron R, Brown K. Impact of
Arillo-Santillán E, Hernández-Ávila M. Estimating the impact of graphic
graphic Canadian warning labels on adult smoking behavior. Tob Control
warning labels on cigarette packs: The auction method. Addict Behav
2003;12:391-395.
2007;32(12):2916-2915.
5. O’Hegarty M, Pederson LL, Nelson DE, Mowery P, Gable JM, Wortley P.
19. Niederdeppe J, Fiore MC, Baker TB, Smith SS. Smoking-cessation media
Reactions of young adult smokers to warning labels on cigarette packages.
campaigns and their effectiveness among socioeconomically advantaged
Am J Prev Med 2006;30(6):467-473.
and disadvantaged populations. Am J Public Health 2008;98(5):916 - 924
6. Hammond D, Fong GT, McNeil A, Borland R, Cummings KM. The
20. Durkin SJ, Biener L, Wakefield M. Effects of different types of
effectiveness of cigarette warning labels in informing smokers about the
antismoking ads on reducing disparities in smoking cessation among
risks of smoking: Findings from the International Tobacco Control (ITC)
socioeconomic subgroups. Am J Public Health 2009;99(12):2217-2223.
Four Country Survey. Tob Control 2006;15(Supp 3):iii19-25.
21. Cavalcante TM. Labelling and packaging in Brazil. Geneva, Switzerland:
7. Hammond D, Fong GT, Borland R, Cummings KM, McNeil AD, Driezen
Organizacion Mundial de Salud, 2003.
P. Text and graphic warnings on cigarette packages: Findings from the
22. Korn EL, Graubard BI. Analysis of health surveys. New York: Wiley-
International Tobacco Control Four Country Study. Am J Prev Med
Interscience, 1999.
2007;32(3):210-217.
23. Borland R. Tobacco health warnings and smoking-related cognitions
8. Thrasher JF, Hammond D, Fong GT, Arillo-Santillan E. Smokers’ reactions
and behaviours. Addiction 1997;92(11):1427-1435.
to cigarette package warnings with graphic imagery and with only text: A
24. Brandt AM. The cigarette century: The rise, fall, and deadly persistence
comparison between Mexico and Canada. Salud Publica Mex 2007;49(Sup
of the product that defined America. New York: Basic Books, 2007.
2):S233-S240.
25. WHO. Guidelines for implementation of Article 11 of the WHO
9. Borland R, Wilson N, Fong GT, Hammond D, Cummings KM,Yong H, et
Framework Convention on Tobacco Control (Packaging and labelling of
al. Impact of graphic and text warnings on cigarette packs: Findings from
tobacco products). Geneva: World Health Organization, 2009.
four countries over five years. Tob Control 2009;18:358-364.
26. IBGE. Síntese de Indicadores Sociais - Uma análise das condições
10. Shanahan P, Elliott D. Evaluation of the effectiveness of the graphic
de vida da população brasileira. Rio de Janeiro: Instituto Brasileiro de
health warnings on tobacco product packaging, 2008. Canberra: Australian
Geografia e Estatística, 2008.
Government, Department of Health and Ageing, 2009.
27. Fong GT, Cummings KM, Borland R, Hastings G, Hyland A, Giovino
11. Fong GT, Hammond D, Hitchman SC. The impact of graphic pictures
GA, et al. The conceptual framework of the International Tobacco Control
on the effectiveness of tobacco health warnings. Bull World Health Organ
Policy Evaluation Project. Tob Control 2006;15(Supp 3):iii3-iii11.
2009;87:640-3.
12. Environics Research Group. Testing new health warning messages for
cigarette packages: A summary of three phases of focus group research.
Ottawa: Health Canada, 2000.

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